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HomeMy WebLinkAbout0895A ----- --- _--- ._ _ _ _. __ . .�._�_�..____---- -._.. WORKERS'COMPENSATION DECIARATION � � L I hereby aHirm thot I hove o tertifico�e of consenr to self � �� � . insure,or a certificata of Workers'Compenso�ion Insu�ance,or ]6Ada]0 o cerfifisd copy�hereof(Sec.3600, b �E�fi�RE°�,e��, qppLICATION FOR PERMIT � Poliq�N0oZ7 �3 com��Y�o,u�u T . SEWER - SEWAGE DISPOSAL ❑Cenified copy is hereby fvrniahed. � �Ce�tilied copy�s filed wi�h the munty bui�ding inapection COUNTY OF LOS ANGELES BUILDING AND SAFETY depar � Dme %� S qpp���a�� �, A-SSt-R.� FOR APPLIC{1NT TO FILL IN 8' CONNECTION DATA CERIIFICATE OF EXEMPTION FROM WORKERS' p��ip�� . COMPENSATION INSURANCF �ooaeu I DS� �Z� ..oI ! �f STATION ��� otvrw � (This�ection need not be compie�ed i(the work involved 6y Ihe ip�iiTv O w�Q y y� �' � ��yp�E a[�Eae�C[ b� �� � uvRo permit is for one hundred dollors(f10p)or lesa.) � I certify�hat in the performonce of ihe work for which �his �pus� ' irvearcam[aroN ��-,TH� permif is iuued,I sholl not employ ony person in any manner Y. CURe F L. M L.TO V.L. � � � v.c.r+o. sa os to become subject to�lhe Workers'Compensalion lows. �,�R r pf C0 i�� �� . f Date Applimot ADDRE55 /•{,J� �1✓7 ,_( / � iGUNN PERMIi Np. ROAD PERMIT NO. NOTICE TO APPIICANi: If, ofter mokin this Certificate of AFRDAVIi w�ivER t��nENt RECORD.INSiq.ND. DATE s a,. .�:h� CA. TE�.�o 7/y-�Gp-O do Exempfioo, you shovid bemme subject to the Workers' �f�A� Compensolion provisions of the Lobor tode,you must forihwith oexa�viipni LOTNO. � MWY.pR ST.WIpEMNG comply wilh suth provisions or this pe�mit shall be deemed � re�oked. etOca TR�CT STAiE ROACHNfNi � UCENSED CONiRACTORS OECLARATION '''o_pr&as atRMiT size oF�or raow or�ior y I hereby affirm Ihat I am licensed under provisions of Chapbr �� , v( 9(commencing wilh Section 7000)of Division 3 of the Busi• eunon+Gs ' p��5 ness and Wofessions Code,ond my license is in full fo�ce and lHoCt. CONiqACIOR �7 tti �� COrM�IECTION CM�RGE FEE . license Numbe�15��1iC.�IOSS� ADD4E55 ' REIMlUItSEMfN! E ' 6 COnfrattOr � � Date �� J CITY TEl.NO. DRfRIR MO. �'�0 BK �v � D�Y V ❑I am eKempt uader Sec. of the L.A.Co. ilctNs�r�o. [iAss ts( �,3 —�. � 3 � �+O DFSCRIPiION OF WORK RE p. PlumbingCodeand/or5ec. ofthe FiN�� yqLIDATION � MDUY SEWER CpW�IfCTING f0 � DATE l` rueuc sew[e ���Z.O-�7 B.&P.Code for the fotlowing reoson i o�� iT a z V�TS M1D/pi OQAINfIELD FlNFt DOfe 1p�$E yyyER CONNECTING 10 BV � PRiVAT V f M Signaturo coNNECT ADdiqnMt etoG.a+ � OWNER-BUILDER�ECLARATION '"a^�T�����R � �0£?9.5 A GJ[qf� FP�CE PIT.DQAIN�iFID I hereby affirm that I am ezempt from the Controctor's License E%TN.ClSSPOOL d+rweu.nu.rvHa¢ � low for the followinq reaaon(Setloo 7031.5,B�isness ond Pro- Ht[a,a[r��a oQ nennop��pusF � • • • • � � fessions Code): s�wEa oa dvoss�t srsrFµ ❑I,oa owner of the property,or my employees wilh wages as '' � � e �G�.JrU Iheir sole compensation,will do the work ond ths srructure � „ �is nat in�ended or offered for wle(Section 70t4,Business � ° " °G l.J C c�i ar+d Profeu�ons Code�. OWNER'S Permit S Q $P ❑I,as owner of+he property,am exclualvely tonfracting wirh AUTHORIZATION TOTAL FEE j=, O � 1,2 2-8 5 �i�!lISGd controcb.a to consh�tt the project(Section�70M, i MAVf Ai THIS DATf A CONiRd.�T W�iM TM4 NEH�N NAMEO CONTN4�Cf04 TO Bus�ness and Profeu�ona Code). ca+netr rHe neove oesta�eeo e■nnNe oweu�r+c Ton+c xiu�e uwea CONSTRUCiION LENDING AGENCY � 1 hmeby affirm thot there is o conafrotlion lending agenty S�Gr�EDiHiS OnVpf � 19� . for Ihe performance of the work for which Ihis permif is �F4p° OWNER$AGEN] iasued(Sec.3097,Civ.C.). ���� Lender's Nome_T ���� . � lender i Addross ' I certify Ihat I hove read this appticofion ond slote thot the � , above informotion is correU.I oqree ro comply wilh all County � ordinances ond Srote lows reg�lating Plumbing and Sewer6, ' . and hereby aulhoN:e represeroa�ives of rhis Counry to eNer , � vpon ihe above-meMioned property 40�inspetlion purpoaes. /� �y� �� �%/(Q.d�d�.fc� ' �� oZ�/�.5 Sipnq vfPermitf�--aql� SEElEVERSEFOREIf►tANAiOMIANGUJ�GE ' V _. . _ _ — -- ,— _ __ _ - -_ / .. - � r,seeror.�s rrcTes . , . . ... ...,�� ` � c3�:�r;r:r:-�.uu,i�i�:r;ni:c[,:t:���rro�;.. ��F��.OV/.�5 ^nr[ v[noo�si;r:cruv•.-' . . ._ . , ________ _ t hcrcL):dlirin�h:it 1 am c�rmp!fror.ftLr fon[r:�c�ur'< .._ . . .- . --— --� Liccn�r I.;n� fur iLe fnllunin�,.t��;��nti LSrrficri 7lli/.i, . n�cv:H��..�y,.;.c �. � . .. .. , . . . .. . .. . __ � " __ ,-,T:ucinrs.e an;l Pruf�°��i<n�s Cndel:.ii�r.ri:e_nr cn:n!;r x�liirf� eCr:ueC oeCm:���=•. 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